HL Deb 28 February 1996 vol 569 cc1459-75

3.27 p.m.

Lord Winston rose to call attention to the level of concern among health service staff about current developments in the National Health Service, and the potential effects upon patients; and to move for Papers.

The noble Lord said: My Lords, first I do not intend to indulge in political invective. In particular, no disrespect is intended to the noble Baroness, Lady Cumberlege. This is not personal. She is honourable and her reputation is high because she appears to listen and clearly cares about the health service. She is highly respected by many of my colleagues throughout the country, but sadly her attitude does not entirely reflect the damage that I feel has been done to the National Health Service over 16 years of this Government. I do not blame her.

Secondly, I do not want to indulge in the politics of invective or hysteria. That is something which occurs in another place. I speak simply from the coal face. I do not come here with a political motive. I do not believe that the National Health Service should be a political football. This House is respected for its reasoned argument and consideration of the facts. I have no desire to be vexatious. However, it is difficult for me not to use strong language for what many of us feel is the disgraceful mismanagement of the National Health Service, for which this Government have been largely responsible. I ask the House to forgive me if I speak with some emotion. These are very emotional matters.

I shall not introduce all the things that are wrong in the National Health Service. Other speakers will deal later with, for example, nursing staff, who, quite rightly, are regarded as the backbone of the health service; general practitioners; primary care and care in the community. I intend to deal mainly with the latest, most important and significant reform; namely, the National Health Service internal market.

The principle is simple enough. Noble Lords will forgive me if I explain what may be well known to some of your Lordships. I do so because many members of the public do not understand the internal market. Indeed, one might add that because the far-reaching changes were thrust without proper consultation upon the National Health Service itself, many people working in the National Health Service, including doctors, do not fully understand them either. I do so because this issue will undoubtedly become one of the most important electoral issues in any forthcoming General Election. Inevitably, too, I have to say, the press will be listening and it is important that what is happening in our health service should be explained to them. In my clinic, I find that very few patients indeed, even those with high qualifications and university degrees, understand the implications to them of the reforms of the health service. This is not a political point. Any hospital consultant can confirm it, unless he is extremely partisan.

Among other things, the reform means that purchasing health authorities, responsible for providing care to their local populations, are given a sum of money to buy medical treatment to meet their catchment area's needs. Providers, which in my case means most hospital based medicine, are the NHS Trust Hospitals. They compete with each other to tender the best contracts for medical services to the purchasing authorities, who then decide on the basis of various criteria whether they will agree to contract for those services.

It would be entirely foolish to say that there are not signal advantages to that system. Indeed, the Government repeatedly take credit for the improvements. The internal market has resulted in many hospitals improving outpatient facilities, improving comfort for patients, improving waiting times in clinics and in some cases improving waiting lists. There is no doubt that that has happened. It has resulted because hospitals are more assiduous and give better information to patients, and because any hospital not making those simple improvements would be likely to lose its contracts and hence its essential funding.

However, I and many of my colleagues feel that the internal market was largely an attempt to mask underfunding and to ration healthcare locally. It has so many adverse facets, as it was envisaged, that it now stands as a monument to government deafness, bureaucratic inefficiency and incompetence. What are its effects? Let me examine some of them.

First, this is the Government of choice. Yet we see a loss of patient choice. It was no idle boast in the old health service that any patient could be referred to the most expert person involved in managing his or her condition. That was one of the star qualities of the National Health Service. It was much envied all over the world, including in the United States of America. For example, in the 1970s and 1980s in my unit at Hammersmith I saw patients for complex surgery from Truro, Inverness, Belfast and all over the United Kingdom. What did that mean? It meant that we grew in expertise and were able to give an unparalleled service. We could provide medical improvements in that particular condition which were copied all over the world. Indeed, post-graduate students came from over 80 countries to study there during that period of time.

What has happened since then? No longer do we get those patients. Now they go for that treatment to their local health authorities. Nobody wants to purchase that treatment because of the competing demands made locally and the need for contracts. It now means that instead of doing 12 or 18 of those operations a week, sometimes in a good week—when beds are available of course—we might do only three to six such operations.

Let me give another example about freedom of choice. Perhaps noble Lords will excuse me if I mention my mother. Her problem took much of my time this week on the telephone. She is a brittle diabetic, very sensitive to insulin. She responds very rapidly to overdoses and underdoses of that drug. She has been cared for at Hammersmith Hospital for 15 years. During that time, she has attended in acute diabetic coma many other hospitals: University College Hospital, the Middlesex Hospital, the Royal Free Hospital and other hospitals in London; and, when she did community work outside this country, hospitals in The Hague, South Africa and so on. She has been to more hospitals than I certainly have. Invariably, after those comas, she came back to Hammersmith because she needed stabilisation. Like many older people with diabetes, bits stop working. Consequently, from time to time she has been to see the urologist at Hammersmith Hospital, the gynaecologist at Hammersmith Hospital, the chest physician at Hammersmith Hospital, renal people at Hammersmith Hospital, the vascular people at Hammersmith Hospital and the orthopaedic people at Hammersmith Hospital.

What happened last week? Despite a bad cold she went to Buckingham Palace to receive an honour for her longstanding public service. It was a cold day and she developed a worsening chest infection. My sister tried to arrange an urgent chest appointment for her to be seen by the Hammersmith Hospital chest physician, whom she knows very well and who knows her. However, because she had not attended that particular part of Hammersmith Hospital for the past two years, where, of course, her notes were, she was refused an appointment; they needed a referral letter from her general practitioner. That was not done on clinical grounds but simply because it was the required form. On the other hand, a general practitioner refused to give her that referral because he was contracting with another providing authority.

That bureaucratic muddle resulted in delay in her being seen in the proper chest clinic. The matter has been resolved because nature intervened and her chest got better despite treatment, as so often happens in medical practice. But many hundreds of thousands of older people in this country do not have somebody who can clout for them and go in there and bat for them.

Secondly, the internal market has meant competition, not co-operation, between doctors. It has meant that many hospitals now compete to try to give the same medical services. I give noble Lords one trivial example from my own area, but it is one that shows very clearly the potential wastage of National Health Service resources. Chelsea & Westminster Hospital has recently set up an IVF clinic. Indeed, it was in the news recently. It was prepared, it said, to try to undercut any of the other National Health Service hospitals in its area and would try to provide a cut-price service on St. Valentine's day and indeed advertised that. Just down the road is Hammersmith Hospital, which has the most expert NHS IVF service in the country, probably in Europe, and is offering that treatment at some 15 per cent. to 20 per cent. less than the cost in the Chelsea & Westminster Hospital. Moreover, Hammersmith Hospital has a huge number of patients, so it is extremely efficient, with a very short waiting list of less than three months, thanks in part, admittedly, to the Government's waiting list initiative.

These are not bad doctors but they have been corrupted by the system in which they work. This week, a patient who had been referred to me by her general practitioner, in error telephoned the Chelsea & Westminster Hospital. Over the telephone, without investigation and without assessment it said that it would offer her treatment which would undercut the Hammersmith Hospital's IVF unit. That would have been in a unit which cannot offer the specialised service and the degree of skill that we can offer because of our huge expertise and large scientific background. What will happen if that practice continues? It will mean that Hammersmith will inevitably lose patients and will have to put up its prices, again increasing the costs to the health service. It means loss of research to an alpha-rated department and probably lowered IVF success rates. Also, because it has not costed its operation properly, it will probably mean that after two years' wastage of money the Chelsea & Westminster Hospital will have to close that unit.

We have a burgeoning administration in the health service. Other noble Lords will speak of that. But one of the things the Government did was introduce a massive administration without the proper information technology. The Secretary of State now wants to decrease the managers by 8 per cent. and to do so, of course, would bring further chaos. In the absence of information technology, they cannot know what the cost of the market is. In fact this is not a market; it is a lottery. There is no serious audit; there is no professional basis for making judgments about buying on behalf of purchasers.

Let me draw your Lordships' attention to a letter I recently received from Professor Jacobs, who is a particularly distinguished professor of endocrinology and Britain's leading reproductive endocrinologist. He says, At present, patients see me either because they are part of a block contract, because they're referred by GP fundholders or because they are extracontractual referrals. The cost of these referrals varies according to type. The number of GPs becoming fundholders is steadily increasing and there is expected to be a new tranche of fundholders on 1st April. Of course, as new contracts are forged, so the number of people who come to us as ECRs varies. It turns out that if a patient is being seen as part of an overperforming block contract and that patient comes from a practice that has become a GP fundholder, by definition the swap from the overperforming block contract to GP fundholding increases the income to the institution. If, on the other hand, the patient was an ECR but now the patient's doctor becomes a fundholder, the institution will almost certainly lose. If the ECR patient does not have many re-attendances, there is no gain to the institution by the patient becoming that of a fundholder, but if the patient has a high rate of re-attendance (clearly a chronic and severe disease) then the institution gains because fundholders are requested, at least by this institution, to pay per attendance".

Lord Callaghan of Cardiff

My Lords, will my noble friend allow me to intervene? I find it a little difficult to follow what he is saying. Can be translate it into a simple proposition so that I can see what he is really saying?

Lord Winston

My Lords, in summarising, Professor Jacobs says, If a patient changes from a 'correctly performing' block contract"— one where they do not see too many patients, even though it would be cheaper for the health service— to a GP fundholding contract then the institution neither benefits nor gains". He summarises by saying, This Alice in Wonderland version of economics is called the contracting system in the National Health Service". That muddle is totally unintelligible. It means that it is unfair because, if a patient is not from a fundholding practice and if he is referred to an over-performing hospital, he may not get his operation this year but have to wait until next year because of the needs of the health service. How many administrators does it take to work that nonsense out?

There are bed shortages due, partly, to the burgeoning administration and the money spent on it. It is interesting to note that nurses have had a small pay rise; chief executives have had pay rises of up to 7.6 per cent. When I asked the noble Baroness, Lady Cumberlege, on 21st February, how the extra money for the nurses' miserable pay rise will be funded or whether it will simply come from trusts' hard-pressed budgets, she mentioned that some would come through, to use her words, improved "efficiencies and other economies". What does that mean? It means improved efficiency and economies in those hospitals. That adds to the increased cost of the administration and, among other things, leads to fewer beds.

The chairman of the Health Services Research recently stated that the pressure on emergency beds is up by 15 per cent. The Middlesex Hospital this week had nine patients waiting for cancer treatment, which was cancelled because it had no beds available for them. One can imagine the problem for those patients who had to wait until the following week to receive their oncological care. That can be cancelled again and only then are they placed on a priority list when they might receive their treatment. I understand that that is the situation in that excellent hospital.

This week I was delayed in coming to this House because there was a young woman in her thirties who was bleeding and for whom I could not find a hospital bed. Three of us had to phone round to try to find her a bed and all the time we were giving instructions over the phone to explain to the people who were with her how to staunch the bleeding by internal pressure. That procedure was carried out in the 17th century but, because there was no other alternative for that patient, we were forced to give that advice. God intervened, otherwise the patient would have died, and the bleeding stopped. But we could not find her a bed in a National Health Service hospital or in Queen Charlotte's Hospital.

In the last few minutes available to me I want to touch on medical education. It is worth bearing in mind that we used to have probably the best medical education in the world. Students came from all over to study in the United Kingdom. It is worth looking at the problems that the universities are now facing. The cut in capital budget, which involves equipment as well as building, is 30 per cent. this year. The PFI, in spite of the Government's claims, cannot possibly replace that funding. It is doubly serious for the NHS because many projects are jointly funded by the National Health Service and health authorities in collaboration with universities.

What do the Government do? They promote the Dearing Report. They kick it into touch at a time when universities are in crisis and so we are delayed for at least another year and it is probable that any implementation of that review cannot take place until 1999. This week we sat through a committee at the Royal Postgraduate Medical School to work out what we could do about the 3 per cent. cut with which we were immediately faced. Because we are particularly well managed, it will not actually prevent our continuing to build the library. But there is no doubt that this is the last cut that we can possibly sustain, and certainly our building scheme constitutes a serious problem.

Another matter which I should like briefly to draw to your Lordships' attention is the Calman reorganisation of junior staff training. The idea of a unified training system is not bad. It is due to start in April. But even my own highly intelligent medical staff who are entering that training system do not understand it. It shortens the training programme for staff in specialist training, but limits the choice of hospital department; it limits their freedom of movement and thence experience; above all, it will inhibit their ability to do clinical and basic research in hospitals—in fact, there will be no advantage in doing clinical research because they are in a set programme. Who will look after the patients? The consultants will not only have to continue their clinical work, but will also have to give lectures to students and demonstrate operations to them. That is a real crisis which worries medical people in the health service.

It is not surprising that we have serious concerns in the National Health Service. In answer to a question I asked on 17th January in relation to the acute bed problem in West London, the noble Baroness, Lady Cumberlege, replied with pride, I believe that we have a remarkable National Health Service; it is a near miracle".—[Official Report, 17/1/96; col. 591.] I weep at that reply. I believe that they do not understand what is happening. We face a serious situation. Of course this Government have spent on the health service. Of course they have spent in real terms—no doubt we shall hear more about that from the Government Benches. We are familiar with their story of spending on the National Health Service. The truth is that this is a spent government. Having spent unwisely on the National Health Service, they may have to pay the cost at the next general election. Sadly, another government will have to pick up the bill.

My Lords, I beg to move for Papers.

Lord McColl of Dulwich

My Lords, before the noble Lord sits down, in view of the fact that he said extensive cuts had been made in the NHS funding, can be say by how much be would like that funding to be increased? Will be also declare an interest?

Baroness Gardner of Parkes

My Lords, this is a time-limited debate and we do not normally have interventions because that takes from other people's time.

3.49 p.m.

Lord Clark of Kempston

My Lords, I am sure that the whole House is indebted to the noble Lord, Lord Winston, for drawing the National Health Service to the attention of your Lordships. I believe that the general public are getting a bit sick of the denigration of what this Government have done in the past 15 or 16 years. Whether it relates to the economy or the National Health Service—perhaps the noble Lord would be kind enough to listen for a few moments—welfare, education or whatever, it is always a question of underfunding.

The noble Lord spoke about cuts in the National Health Service. What he did not say is that those cuts were projected expenditure which the Treasury then reduced. That is not a cut. There were increases, but not as much as asked for by the departments. I remind your Lordships that when one considers the situation between 1979 and today, some £41 billion has been put into the National Health Service. In simple terms, that means that for every man, woman and child in the country in 1979, £433 was spent on the National Health Service. Today the figure is £697. In real terms the increase in the National Health Service budget is 66 per cent.

Noble Lords will probably ask how that has been done. In my view, it has been achieved because of good national housekeeping. Perhaps I may return to that in a few moments. The noble Lord agreed that more patients are being treated. The figure is now 3 million. Waiting time has been reduced; and the noble Lord paid tribute to that. Those are the kinds of things that we need to talk about regarding the National Health Service. Fund-holding for GPs has been a great success. God forbid that the noble Lord's party should ever get into power!—they would abolish that.

What we must remember about the National Health Service is the fact that the advances in medicine are beyond our comprehension when one considers what patient treatment was some 20 or 30 years ago. There is no comparison with today. There are so many new cures and we are living longer. Quite obviously these factors produce extra drain and strain on the National Health Service.

As regards the nurses, as your Lordships know, the Government have accepted the independent review body's offer of 2 per cent. In addition to that, there is whatever the nurses can negotiate locally. I believe that even the noble Lord will pay tribute to the fact that the National Health Service is generally very healthy. It employs more nursing staff, care staff and so on.

Perhaps I may return to the question of nurses' pay, and something which the noble Lord did not mention. In real terms, over the period of this Government since 1979, nurses' pay has increased by about 79 per cent. Perhaps I may remind the noble Lord that under the last Labour Government in real terms nurses' pay was reduced by 3 per cent. How does that square with what the Labour Party are saying today? It is hypocrisy for it to criticise the National Health Service. I remind the noble Lord of the time when the Labour Government had to go cap in hand to the IMF. That meant a cut-back not only in nurses' pay, but also a tremendous reduction in capital expenditure within the National Health Service and other departments.

Perhaps I may now turn to hospital trusts, to which the noble Lord paid some tribute. As regards hospital services, 98 per cent. of them are hospital trusts. Consequently, that means that there is more power held locally in running the local health service. The Government are shortly to abolish the regional health authorities. That again will create more efficiency and more local power as regards the National Health Service.

I referred earlier to how this was being done. The Government have increased taxpayers' expenditure on the National Health Service and also on other departments such as education. That has been achieved because of the Government's economic policy. Whatever one likes to say about this Government, their economic policy has reduced inflation from 26 per cent. to under 3 per cent. That helps everybody: it helps the National Health Service and the nurses. Bank interest rates are down from 15 per cent. to something like 6.25 per cent. and they are falling. I have no doubt that they will fall further. Unemployment is also down. The unemployment figures have come down for 29 successive months. It is due to good national housekeeping.

When one considers inward investment, that is proof positive that the foreign investor looks on this country as a good bet and a good place in which to put his goods. Exports have increased and also the number of small businesses. This is good national housekeeping. The standard of living has improved for everybody in this country by about 40 per cent.

These are the factors which determine whether any government can spend money on, for example, education, the National Health Service or whatever. Government are only the trustees of the taxpayers' money and unless the economy is buoyant then this money will not be available for the National Health Service. That is how this Government have increased expenditure on the National Health Service.

When one hears from Labour Members of Parliament and noble Lords in opposition, one never gets a figure or an explanation in relation to their grandiose schemes. Whether that is the frivolity of opposition, I do not know. They announce grandiose schemes but they never price them. That is what the general public want to know. If expenditure on the National Health Service is to be increased, the public want to know where the money is coming from. Will it come from the taxpayer; will it be borrowed, or what? Will it lead to an inflationary spiral as we had under the last Labour Government?

If the Labour Party want to show any credibility, it really is high time that the leaders of the Labour Party came out fair and square and said, "All this is going to cost more. More teachers will cost the taxpayers more. More money spent on the National Health Service is going to cost so much more". At the end of the day the Opposition should say where the money is coming from. That is something they shy away from. It is becoming so serious that I believe the Opposition are losing credibility. Anyone in opposition can promise, but it is only if one is in government that one has to deliver and that can only be done if there are the resources available.

The future danger for this country is that if there were a change in government, that would mean a minimum wage. I believe that all economists and many Members of the Opposition agree that that would increase unemployment. If we accepted the social chapter that would increase the unit costs of production, which even the Germans and the French now realise. They realise that the social chapter is not really working. If there were a change of government and we ended competitive tendering, that would be disastrous so far as the economy is concerned. Any diminution of our economy must mean that there will be fewer services for the National Health Service. Therefore, I trust that my noble friend will resist the criticism.

3.59 p.m.

Lord Walton of Detchant

My Lords, I am grateful to the noble Lord, Lord Winston, for introducing this debate and for the opportunity of contributing to it. At the outset I must express my sincere apologies to him and to the noble Baroness who will reply for the fact that I only learnt last week that this debate was to be held. I had already accepted a pressing engagement for later this afternoon which may prevent me from listening to the entire debate. I shall read all the closing speeches.

I have been a fervent supporter of the National Health Service since it began in 1948. That resulted from the fact that my salary as a medical registrar at the very beginning of the NHS was immediately increased from £400 to £775 per annum. In 1958 I became a consultant. I later held an honorary Chair and later still had six university sessions as a professor while retaining five NHS sessions. Even when I was translated to the dreaming spires of Oxford in 1983, I continued to hold two honorary sessions as a consultant until some four years ago when, on reaching a certain age, I was told by the health service that my honorary clinical contract had expired and that I could visit the hospital for social reasons, but without any clinical facilities.

That introduction may be irrelevant, but the point I want to make at the outset is that I lived through the halcyon days of expansion in the NHS when my department and the facilities and staffing available continued to expand. We saw almost incredible advances in medicine with imaging, transplants, spare parts surgery, immunology, rehabilitation, cardiac surgery and many more developments. I eventually headed an academic and research unit which received referrals from all over the country and, indeed, from many parts of the world. Those were wonderful days—they were days when I was very proud to work in the NHS. Indeed, we can still take a justifiable pride in our National Health Service, upon which we still spend less than 6 per cent. of our gross domestic product, one of the lowest proportions spent by any developed country.

However, we have an ageing population and we have a population with greater expectations than ever before about what the NHS can provide. Why should they not have hip replacements? Why should not everyone who can benefit from it have cardiac surgery? The introduction of new expensive drugs such as Beta Interferon for multiple sclerosis and of new procedures has imposed immense demands on our NHS.

I still believe that the NHS provides the best emergency care in the world, but even in the early 1980s we began to see the gathering clouds on the horizon and to recognise that no developed country can ever produce a health service which provides every conceivable medical treatment irrespective of cost. At that time I suggested, rather interestingly, the possibility of predicated taxation and the introduction, which I believe that the country would welcome, of an index-linked income-related health tax, but I was told that the Treasury would never stand for it. I often wonder whether we will ever be able to relax the iron hand of the Treasury in promoting desirable developments. However, that is water under the bridge.

The Government's response to the problems that we saw at that time was to introduce a review of the National Health Service. I believe that what has followed has in many respects been very beneficial: better management and better cost control, with doctors for the first time fully understanding the costs of the procedures and forms of treatment that they offer. I think that GP fundholding has many great benefits to offer, although there is clearly a risk of a two-tier service. Nevertheless, with the academic and vocational training of general practitioners we have seen an enormous improvement in community care and in the quality of British general practice which I now believe to be the best in the world.

The contractor-customer principle carries certain benefits hut, as the noble Lord, Lord Winston, said, it has also brought problems, some of which were highlighted in a report on medical research in the NHS in the light of the reforms which was based on a Select Committee inquiry which I chaired and which was debated in your Lordships' House last year. There is no doubt that tertiary referrals for patients with difficult clinical problems requiring specialised treatment in centres of excellence have fallen sharply, if only because local managers have taken the view that the treatment can be equally well offered in a local hospital instead of sending the patient to, say, Hammersmith or to the Newcastle General Hospital, where I once worked, or to other centres where highly specialised care can be provided.

I know full well that the Minister will give us much information about the increasing resources that are being devoted to the National Health Service, about the reduction in waiting lists and the increased standard of care. I accept all the points that she will make: more money is being spent on the NHS. Indeed, I congratulate the noble Baroness on her spirited and dedicated advocacy of the National Health Service, which has invariably won the respect of the entire House.

However, without doubt the storm clouds are gathering again—and they are deepening. Morale in many of the professions in the National Health Service in many of the professions is at its lowest for a decade. Many hospitals have improved their standards of care through day surgery and short stays, but I believe that the closure of acute beds has happened too fast. That can be seen from isolated examples, such as the Sidcup patient who had to be flown to Leeds, the Stepping Hill case where a scanner was not available in the evening, and the recent story of the cancer care unit in Bristol which has had to turn away patients. Those are isolated examples occurring against a background of increasingly high standards of general medical care, but they are happening far too often. The National Association of Health Authorities and Trusts has produced figures to show that over the past three years there has been a 14 per cent. increase in emergency admissions. One of the inevitable reasons for that is our ageing population.

But why in certain areas has there been a veritable stampede of consultants seeking early retirement at the age of 60 rather than wanting to continue to serve the NHS to the age of 65? Why are we unable in many areas of the country to recruit consultants in psychiatry, anaesthetics, paediatrics, accident and emergency, and orthopaedics? Why in the region in which I used to work has the Shotley Bridge Hospital had to close its accident and emergency department because it is unable to recruit doctors to staff it? When I was the Warden of Green College and when I was Dean at Newcastle many of the brightest medical students wanted to enter the new, developing and exciting branch of general practice with vocational training, but there has been a 14 per cent. reduction in the number of young doctors entering general practice training as registrars. I shall not comment on the nursing shortages as I am sure that other noble Lords will mention them, but I do believe that the recent pay award was unfortunate, to say the least.

I turn now to academic medicine. Professors, senior lecturers and lecturers have a clinical contract and do a great deal of clinical work, but the evidence from our Select Committee inquiry showed that at present 24 clinical Chairs in the United Kingdom are vacant for lack of suitable applicants, 10 of them having been vacant for more than 12 months. Fortunately, the Committee of Vice-Chancellors and Principals has established an inquiry under Sir Rex Richards of Oxford to look at the future of clinical academic medicine which, without any question at all, is in crisis.

Yesterday we considered the Reserve Forces Bill on Report. That presents us with another little problem. I served for 16 years in the Territorial Army and was happy eventually to command a Territorial Army general hospital. I understand that there is now pressure from managers not to allow doctors to enrol in the reserve forces in case they are called out in an emergency. There was a problem during the Gulf War when the NHS suffered through the call up of many doctors in the Territorial Army.

Those are just a few of the problems which the NHS is facing. I believe fervently in its future. I believe that the NHS is one of the things of which this country may be justly proud. However, I urge the noble Baroness, her colleagues and her right honourable friends to undertake discussions with the medical royal colleges, the nursing profession and many others, and to look at some of the emerging problems to which I have drawn her attention because they present a considerable threat to the future of our beloved NHS.

4.8 p.m.

Baroness Hayman

My Lords, it is a pleasure to follow the noble Lord, Lord Walton of Detchant, and to express my gratitude and, I am sure, that of the House to my noble friend Lord Winston for initiating this debate. We are grateful to him—the NHS is grateful to him—for his professional contribution over many years. I know that that gratitude is shared by many patients.

My only quarrel with my noble friend lies in his framing of the Motion. Inevitably he started with the word "staff". When I talk about the NHS I think that it is a good principle to start with "patients", but that word does not appear until the very end of the Motion.

The noble Lord, Lord Clark of Kempston, said that we should declare our interests. I declare an interest as the Chair of an NHS trust hospital. But there is an interest that we all share as patients or potential patients of the National Health Service. It is a very real interest, even for those who are covered by private insurance and who normally take their healthcare elsewhere. I refer to the fact that there is no alternative in terms of emergency provision to the National Health Service. We all may have cause to be grateful for and be dependent on the qualities of care within that service.

There is a justification for focusing on the concerns of staff in our deliberations today because it is proper that we should be aware—and that anyone involved in the political process should be aware—that it is not within the purview or power of a Secretary of State to deliver the quality of care and the kind of health service to which we aspire. That can only be delivered by the staff who work within that service. It is only because of the commitment of the staff who have worked within that service over generations that we have the National Health Service of which we are all, I think, rightly proud.

We have therefore to take very seriously the concerns of people who work within the service. I hesitate to make wild assertions about morale. It is very dangerous to talk about morale because it is a difficult and notoriously dangerous area to try to quantify. In my experience of the public services it is unusual for members of staff to come up to you and tell you how high morale is. That having been said, it would be wrong not to acknowledge the wide-ranging and deep-rooted concerns that exist among various groups of staff within the National Health Service. The noble Lord, Lord Walton, alluded to some of them.

When the explicit commitment of the National Health Service is to a primary care led service, we must all be concerned about the extremely worrying difficulties of recruitment into general practice. General practice in this country has been the jewel in the crown of the National Health Service. It has been of tremendous importance to the quality of care for individual patients and to the continuity of that care. It has also been of crucial importance in keeping down the costs of the NHS because of the gate-keeping role of the general practitioner. We sacrifice that role and demoralise those people at our peril. The difficulties of recruitment into general practice are something that should cause very great concern.

Looking at morale, the nursing profession is also faced with enormous changes. Its members are being asked to take on—and want to take on—developing roles in response to our commitment, as a service, to reducing junior hospital doctors' hours, by expanding their practitioner roles. That is foolish in the extreme when recruitment is getting more and more difficult. There was a time during the recession when recruitment was not as difficult, when there was a great stability in the nursing workforce, but that is gradually changing and recruitment is becoming more and more difficult. It was foolish as well as insulting to treat the nurses' pay round as we have done this year.

As to the state of morale among managers, it is very easy to attack managers. It is very easy to call them bureaucrats, to talk about grey suits and to assume that if we only got rid of them and saved the money we spent on them it would solve all the problems within the NHS. The NHS is an enormous, expensive, labour-intensive and extremely complex organisation, and it deserves the highest quality of management.

It is hypocritical to say that we have to cut the costs of management without taking away any of the tasks of management. My quarrel—one of my many quarrels—with the reforms is that the tasks that have been put on the NHS have not been of management but of bureaucracy; of dealing with the nightmare of year-on-year contracting which takes up huge amounts of time and energy to very little avail, and which turns it into an organisation more interested in patients' postcodes than their prognosis, and into a paperchase of trying to build different parts of the service for different bits of care that is given. That has been a terrible distraction, among the reforms, from the very real problems that affect the service.

I was surprised at the speech of the noble Lord, Lord Clark. It seemed to me that he was harking back to a vision of a Labour Government that I did not very much recognise, and to a vision of a future Labour Government—which I certainly did not recognise—with a little synopsis in the middle of an NHS under the Conservative Government that no one that I know who works in the NHS would recognise. Certainly everything in the garden is not as rosy as he suggested.

I am not suggesting that there are simple answers or that these are black and white questions. There are, internationally, huge and recurring problems that have been alluded to: the problems about rising expectations, about changes in demography and about what we can do by the extension of technology, which has both pluses and minuses on the treatment and the costs side. They are dilemmas for every country and every health service in the world, whether you are in Bangladesh and paying $10 per head per year on health care or in the United States where the government is looking at $2,500 per head on health care. We are still talking about affordability, about the best structures for delivering high-quality, cost-effective care. They are real and difficult issues that we must tackle.

There are real and difficult issues in this country that we have to tackle. We must look at the Calman changes for doctors in training and the changed role that we are asking consultants to take on. The correspondence in the BMJ illustrates the real concerns about who will deliver the care to patients when consultants are doing more teaching, junior doctors are doing more learning, and there are more and more demands from patients. So there are real issues there.

There are real issues raised by the Culyer Report and how we will finance research within the NHS. There are real issues about what a primary care led NHS means, what the public think it means and how much they want to support it. There are real issues, which were discussed in the House recently, concerning community care, the spectrum of community care and whether, when we closed the long-stay institutions, for very good reasons, we perhaps looked after patients who were already in them but did not anticipate well enough what would be needed for patients who would have gone into those institutions in the future. That was a real problem.

There are enormous, real difficulties. No one within the health service thinks that we can spin gold out of straw. We know that there are resource constraints and we know that there are real dilemmas about priorities that all governments have to face. What distresses me is that we have spent the past few years pretending that the market had a solution to those problems and that we could deal with structures and not deal with the real problems, and that we have been diverted from facing them.

4.19 p.m.

Baroness Gardner of Parkes

My Lords, it is good to have this opportunity to debate the NHS, and I thank the noble Lord, Lord Winston, for his choice of subject. To listen to him, is to hear one side only of the health service story. Let us not be too depressed. There is a great deal of good news to tell. Indeed, one concern that the noble Lord did not mention is that many staff working in the NHS feel that they tend to be taken for granted by the public who do not appreciate their great contribution. Instead of flagging up the marvellous results they have achieved, and valuing the efforts that have gone into that, they hear only moans about what more the health service should do. An example of that is that 17 per cent. of patients failed to keep their NHS appointments in hospitals.

My interest as chairman of the Royal Free NHS Trust is one that I have declared often, and I do so again. In many ways, the introduction of the Government reform of the health service has been highly successful. At the Royal Free we have treated more in-patients each year. This year we have treated 25,000 more than in 1990. We have now more beds, many new facilities, a newly built renal unit, many state of the art pieces of new technology, a gamma camera, CT scanners and MRI scanners. We are currently developing an expanded A&E department. Next year we shall have increased out-patient facilities.

Recently a world famous actor came to the hospital to unveil our replacement and updated CT scanner—a great improvement in technology and patient comfort. He asked me who had donated it, and expressed great surprise when I was able to tell him that it came out of the national health budget. He had been led to believe that the health service was so strapped for cash that only generous donors or public appeals could supply any equipment even if it were considered to be essential. The patients and staff need to know that the health service is still making a huge investment in patient care.

It is true that the staff are working harder than ever. That is true also of jobs in industry. Those who are in employment find that the demands made on them are increasing. New computer technology which is planned to assist can often involve considerable extra effort, especially during a learning phase. Hospital patients dislike the fact that the nurse or receptionist can see the screen while they cannot. That causes friction and adds to the staff burden.

The reduction in junior hospital doctors' hours has been good for them, and we hope for the patients, but it means that nurses are taking on duties which were previously done by the junior doctors. Someone else will need to take on the duties that were done by the nurses. NHS work is never ending.

In any health system there are always concerns about growing demands and the availability of resources to meet those inevitable demands. The demographic changes of an ageing population and the constant advance of technology are familiar to us all. I know from my own experience that the staff express anxiety about that dilemma.

Local pay is an issue. Trusts have supported the introduction of local pay, and it is right that successful trusts should have the opportunity to reward staff fairly; but there is anxiety that with the additional 3 per cent. central funding for pay in the NHS, it will be difficult to meet reasonable expectations above that level, especially when central decisions on those staff with national arrangements—for example, the Doctors and Dentists Review Body groups—have given rises in excess of 3 per cent., and for senior registrars and registrars at a nett cost of 4.63 per cent. in 1996–97.

Some issues are creating staff concern in the Royal Free Trust. There has been a national reduction in the funding of HIV/AIDS services in the light of the anticipated flattening out and potential reduction in new AIDS cases in the future. However, there is concern that those national reductions take little account of local variation in the delivery of service at designated treatment centres. Our trust has seen a continuous growth in the numbers of HIV/AIDS cases under treatment—20 per cent. more last year. As those patients can go to any treatment centre, and often choose to be away from their own areas, predictions cannot be made accurately. The actual trend needs to be recognised in funding terms. The Minister has agreed to look retrospectively at where those patients receive their treatment.

The Royal Free is one of the largest providers of specialist services to haemophiliacs in the country. Great strides have been made in the treatment and care of those patients, but the costs are rising inexorably. New methods of purifying the products necessary for blood clotting are being developed. They will increasingly ensure safe transfusion, but they cost more. Those services are not supported by any national funding arrangements and must be met from local resources. The rising costs cause huge pressure on existing budgets and have a knock-on effect on other hospital services in-year.

I quote those two points as they are examples staff have taken up with me of highly specialised treatments where the financial pressures are concentrated on only a few treatment centres in the whole country.

New management procedures have been successful, and there is a greatly improved standard of managers. Our trust does not have all the excess management staff of which I hear talk. Our managers work hard with all the other staff, and a genuine effort is put in by all in the trust to provide the best possible patient care. Better use is made of beds. Complaints, no matter how few in number, are taken seriously, as we aim to learn valuable lessons and to ensure that mistakes are not repeated.

It is time to reassess the Patient's Charter standards, to see whether they have proved to be the most relevant or whether they require amendment. There is a case for a degree of variation to cover chief teaching hospitals where the aim is to combine education and treatment.

Health of the Nation priorities should be reviewed regularly. The health needs of our population are changing constantly. We have good NHS staff and a good NHS. We must be sure that that continues in the future and that the efforts of those working in the NHS are valued. A number of conflicting statements have been made in the debate. For example, the noble Baroness, Lady Hayman, spoke of when GPs were better, but I think they are better now. Many GP practices now offer amazingly good services. They run minor accident centres.

Baroness Hayman

My Lords—

Baroness Gardner of Parkes

My Lords, I am sorry but I cannot give way as my time has almost run out. What we have found is that the better the GP the greater the hospital referrals. I may have misunderstood what the noble Baroness said. The discussion was about a primary-care led health service. If there are better informed GPs who look after their patients better there is more work in the hospitals and not less.

The noble Lord, Lord Winston, referred to Caiman. We are concerned about the costs and the structures of Calman. We estimated that in the past doctors had 46,000 hours of experience before they became consultants. Although opinions seem to vary on this, they will now have between 13,000 and 18,000 hours of experience. There will be dramatic changes. As regards the funding, I understand that the department is aware of the pressure that that will put on hospitals and that that will be taken into account in the planning of the health service.

The noble Lord looked two ways. He wanted all these major services in big centres, and yet he complained that they had them in too many; for example, the Westminster and Chelsea, and the Hammersmith. We cannot have it both ways. I am proud of our health service. I wish to see it continue.